Atlas of optical coherence tomography for approaching macular diseases
By Ameen Marashi, MD (Late 2020)
Optical coherence tomography (OCT) is one of the most critical imaging technique that offers non-invasive in vivo macular tissue evaluation, which becomes essential in day to day retinal practice when approaching and managing patients with macular diseases.
OCT offers the ability to assess treatment efficacy and follow up macular changes in patients with macular diseases and reveal biomarkers that may help predict visual prognosis.
This atlas contains more than 230 OCT images covering normal OCT scan findings, and types of OCT scans, and pathological findings along with the most common macular diseases such as vitreomacular interface abnormalities, macular hole, retinal vascular diseases, Bruch's membrane choroidal vasculopathy, hereditary diseases cystoid macular and posterior segment trauma.
This atlas help ophthalmologists interpret OCT easily to approach and follow up patients with macular diseases efficiently.
I would give special thanks to Barbara Parolini for editing the vitreomacular interface and macular hole chapter with me.
I would love to thank the contributors for their generosity and courtesy of OCT scans in certain cases.
Atul Dhawan, Hina Khan, Zrenie ophthalmological center, Sengul Ozdek, www.eyecarePD.com, and Mohamed Ahmed Tawfik
Atlas is available at :
Clinical guidelines for approaching and managing common retinal diseases: Making retina straightforward
By Ameen Marashi, MD (Mid 2020)
The clinical guidelines for approaching and managing common retinal diseases are to help and to inlight the retinal path of each ophthalmologist. Because experience is not taught in books, I deliberately made something different and combined the sum of evidence-based medicine and several references to deliver that guidelines for a safer clinical practice. I know this is not an easy task, and some cases require individualization for each patient and that the world of the retina is broad with a bumpy path. However, I have striven to find a straightforward way that leads you to the righteousness of the correct clinical evaluation, which I didn't find at the beginning of my entry into the world of the retina. I hope you find these guidelines useful in your daily retinal clinical practice.
دليل الممارسة السريرية لمقاربة وتدبير الأمراض الشبكية الشائعة: جعل طريق الشبكية أسهل
(Arabic Edition) Kindle Edition
By Ameen Marashi (Mid 2020)
تعتبر الأمراض الشبكية من إحدى الأسباب المؤدية لتدني الرؤية في ممارستنا السريرية
يوجد اختلاف في وجهات النظر حول مقاربة وتدبير الأمراض الشبكية ، لذا طلبت مني الجمعية السورية لأطباء العين كتابة دليل ممارسة لمقاربة وتدبير الأمراض الشبكية التي نواجهها في حياتنا اليومية لمساعدة الزملاء وأطباء عيون المستقبل لاكتساب الخبرة في مقاربة وتدبير الأمراض الشبكية فقط
اعتمدت على أحدث التوصيات السريرية المعتمدة على الطب المسند بالدليل
لايحتوي الكتاب على سرد للآلية الإمراضية للأمراض أو التصنيفات أو التشاخيص التفريقية
يحتوي هذا الكتاب على 21 دليل ليُغطي 30 مرض شائع في الشبكية
يُساعد الدليل أطباء العيون على معرفة أهم الأشياء المطلوب سؤالها للمريض عند أخذ القصة السريرية وتقييم الحالة بالفحص السريري ولمعرفة الفحوص العينية المطلوب إجراؤها وما نتوقع مشاهدته بها
يناقش الدليل الخيارات والخطط العلاجية للحالات السريرية الشائعة في الممارسة العملية ومتابعة المرضى ومعرفة إنذار المرض مابعد العلاج مع مخططات بيانية تُلخص مقاربة وتدبير هذه الأمراض
إن مقاربة وتدبير الأمراض الشبكية ليست بالأمر السهل وتحتاج لعدة سنوات من الخبرة و لزمالة جيدة
اجتهدت في هذا الكتاب لتقديم دليل ممارسة بلغة مفهومة بسيطة مع مخططات بيانية لمساعدة أطباء العيون بالقيام بممارسة سريرية آمنة عند مقاربة وتدبير الأمراض الشبكية
عليك أن تعرف أن هذا الكتاب ليس بديلاً عن الخبرة الشخصية الفردية بإجراء المناسب لكل مريض اعتماداً على حالة المريض وخبرة الطبيب والموارد المتاحة
لدي حلم بأن يصبح الدليل كمشروع مفتوح (open source) بحيث يتمكن جميع أخصائيي الشبكية حول العالم بالمساهمة بإضافة معلومات جديدة وأتمنى أن أتمكن من تطوير هذا الكتاب في السنوات القادمة ليبقى مواكباً لأحدث التوصيات العالم
Clinical Diabetic Retinopathy: Step by step for management and decision making
By Ameen Marashi, MD (Late 2017)
Diabetic retinopathy is the fifth leading cause of blindness and is very common in ophthalmic practice, dealing with it is a daily challenge, and treating patients with diabetic retinopathy properly can save sight and improve their quality of life.This book aims to help comprehending the pathology, imaging techniques, therapeutic modalities, patient approach, clinical features and straight forward treatment plans of diabetic retinopathy, maculopathy and their complications in a modern and practical manner with the help of algorithms and illustrations which provides cutting edge information and covering various clinical scenarios such as proliferative and nonproliferative diabetic retinopathy, vitreous hemorrhage, tractional retinal detachment, rubeosis iridis, central and non-central diabetic macular edema, vitreomacular abnormalities, macular ischemia, and treatment complications.
: السريريات في اعتلال الشبكية السكري
خطوة بخطوة نحو اتخاذ القرار العلاج
By Ameen Marashi, MD (Early 2018)
اعتلال الشبكية السكري خامس سبب للعمى وهو شائع جدا خلال الممارسة السريرية ويعتبر التعامل معه أحد التحديات اليومية ، علماً أن علاج مرضى اعتلال الشبكية السكري بشكل صحيح قد يحافظ على رؤية المرضى ويحسن نوعية حياة المرضى.
يهدف الكتاب إلى المساعدة في فهم الألية الإمراضية وطرائق تصوير وأساليب علاج ومقاربة المرضى والمظاهر السريرية ووضع خطة علاج مرضى اعتلال الشبكية السكري واعتلال اللطخة واختلاطات العلاج بطريقة عملية وحديثة بمساعدة خوارزميات ورسومات كما يغطي الكتاب العديد من السيناريوهات التي قد تواجه الطبيب كاعتلال الشبكية السكري التكاثري واللاتكاثري ونزف الزجاجي وانفصال الشبكية الشدي وتوعي القزحية ووذمة اللطخة السكرية اللامركزية والمركزية و الاضطرابات اللطخية الزجاجية وإقفار اللطخة واختلاطات العلاج
By Ameen Marashi, MD (2013)
This book is written as algorithms and text conﬁguration, where algorithms are made to help us, doctors, easily diagnose and treat patients with the most common uveitis cases, where the text is made to summarize diseases in the algorithms.
This book is divided into chapters such as principles of treatment infectious, noninfectious inﬂammatory, masqueraded diseases, and algorithms. As you noticed, there are no pictures in the text chapters because I don't have pictures of uveitis cases that are mine, and I don't have any attention to violate any copyrights.
Perspective on retinal findings in COVID-19
October 13, 2020
Editorial about concerns for OCT findings for patients with COVID-19 previously reported Marinho. et al.
Suprachoroidal injection of triamcinolone for DME treatment
Diabetic macular edema (DME) is a leading cause of early-onset vision loss and blindness among working-age adults. The disease is commonly treated with steroids. Targeting the suprachoroidal space may represent a safe and effective option for steroid delivery in patients with DME.
Safety of 6000 intravitreal dexamethasone implants.
Apr 30, 2019
To evaluate the real-life safety profile of intravitreal dexamethasone implant injection for various retinal conditions.
Retrospective multicenter analysis of intravitreal dexamethasone implant injections (700 µg) due to various retinal conditions including central retinal venous occlusion (1861 injections), diabetic macular oedema (3104 injections), post-surgical cystoid macular oedema (305 injections) and uveitis (381 injections). The eyes were evaluated mainly for the occurrence of adverse events such as glaucoma, cataract, retinal detachment and endophthalmitis along during the follow-up period.
A total of 6015 injections in 2736 eyes of 1441 patients (mean age of 65.7±12.9 years) were in total analysed over an average period of 18 months (range 6 months to 102 months). A total of 576 eyes (32.5% of the phakic eyes) developed cataract requiring surgical intervention. However, visually insignificant cataract progression was observed in another 259 phakic eyes (14.6%) which did not require surgical removal. A total of 727 eyes (26.5%) experienced an intraocular pressure (IOP) rise of >25 mm Hg, with 155 eyes (5.67%) having a prior history of glaucoma and 572 eyes (20.9%) having new onset IOP rise. Overall, more than 90% of eyes with IOP rise were managed medically, and 0.5% eyes required filtering surgery. Endophthalmitis (0.07%), retinal detachment (0.03%) and vitreous haemorrhage (0.03%) were rare. There was no significant change in visual acuity (p=0.87) and central macular thickness (p=0.12) at the last follow-up.
This is the largest real-life study assessing the safety of intravitreal dexamethasone implant injections in various retinal conditions. Cataract progression and intraocular pressure rise are the most common side effects, but are often rather easily manageable.
Treating macular edema secondary to retinal vein occlusion with suprachoroidal injection of triamcinolone acetonide using custom made needle
Oct 22, 2018
Purpose: To report the efficacy and safety of suprachoroidal injection of triamcinolone acetonide using custom made needle in a 76 years old male with macular edema due to retinal vein occlusion.
Methods: This was interventional case report, of a symptomatic 76years’ old male with history of macular edema due to branch retinal vein occlusion, underwent for clinical examination and follow up with optical coherence tomography at baseline, one week, 4weeks and 8 weeks of treatment with single injection of triamcinolone acetonide in suprachoroidal space using custom made needle with evaluation efficacy and possible of ocular complications.
Results: Improvement of best corrected visual acuity from baseline 20/100 to 20/30 at 8 weeks with resolution of macular edema and intraretinal hemorrhages at 8weeks from baseline with no signs of ocular complications.
Conclusions: Injection of triamcinolone acetonide in suprachoroidal space using custom made needle seems to be safe and effective in treatment macular edema due to retinal vein occlusion.
Safety of 5914 intravitreal aflibercept injections
Aug 11, 2018
Purpose To analyse the pooled safety data of intravitreal ziv-aflibercept (IVZ) therapy for various retinal conditions.
Methods This was a retrospective, observational study which included patients from 14 participating centres who received IVZ. The medical records of patients who received IVZ from March 2015 through October 2017 were evaluated. Patient demographics and ocular details were compiled. Ocular and systemic adverse events that occurred within 1 month of IVZ injections were recorded and defined as either procedure-related or drug-related.
Results A total of 1704 eyes of 1562 patients received 5914 IVZ injections (mean±SD: 3.73±3.94) during a period of 2.5 years. The age of patients was 60.6±12.8 years (mean±SD) and included diverse chorioretinal pathologies. Both ocular (one case of endophthalmitis, three cases of intraocular inflammation, and one case each of conjunctival thinning/necrosis and scleral nodule) and systemic adverse events (two cases of myocardial infarction, one case of stroke and two deaths) were infrequent.
Conclusion This constitutes the largest pooled safety report on IVZ use and includes patients from 14 centres distributed across the globe. It shows that IVZ has an acceptable ocular and systemic safety profile with incidences of adverse events similar to those of other vascular endothelial growth factor inhibitory drugs. The analysis supports the continued use of IVZ in various retinal disorders.
Non-central diabetic clinical significant macular edema treatment with 532nm sub threshold laser
May 17, 2018
Purpose: is to determine if Sub Threshold Laser at 532 nm can reduce macular thickness in non-central Clinical Significant Macular Edema (CSME) and stop the progression of non-central CSME to central CSME.
Methods: 8 eyes in 6 patients were diagnosed with non-central CSME using OCT and were treated with Sub Threshold Laser at 532 nm using 5 % duty cycle using high density low intensity application on the area of the edema, retreatment was allowed with Sub Threshold Laser whenever macular edema worsening.
Main outcome and measures: A complete fundus exam including best-corrected visual acuity changes within 24 weeks, improvement of non-central retinal thickness and monitoring glycemic control.
Results: Reduction of retinal thickness from 384.5±64.5µm to 311.33±51.7µm at 24 weeks follow up (P<0.05) without changes of best corrected visual acuity along with reduced risk of progression to central CSME and visual loss with no sign of laser burns at the macular area.
Conclusion: 532nm subthreshold laser is effective in NON-central CSME treatment for 24 weeks follow up and reduce the risk of visual loss due development of central CSME without causing retinal scars.
Trends in treating chronic persistent diabetic macular edema
Apr 18, 2018
Chronic persistent diabetic macular edema responds poorly to intravitreal Anti-VEGF treatment, due to dominance of inflammatory cytokines in the pathogenesis, optical coherence tomography is important tool to evaluate structural changes and visual prognosis in diabetic macular edema. Multiple studies showed the efficacy of intravitreal steroids treatment and intravitreal Anti-VEGF agents may reduce the risk of visual loss in cases of chronic persistent diabetic macular edema. When optical coherence tomography shows signs of disorganization of inner retinal layer and interruption of ellipsoid zone in light of diabetic macular edema that responds poorly to Anti-VEGF treatment then switching to intravitreal steroids recommended.
Panretinal Photocoagulation versus Intravitreal Bevacizumab for Proliferative Diabetic Retinopathy Treatment
Jun 30, 2017
Advances in Ophthalmology & Visual System
Purpose: It is to determine the visual acuity outcomes at 1 year in eyes with proliferative diabetic retinopathy using pan retinal photocoagulation compared to intravitreal Bevacizumab 1.25 mg instead of Ranbizumab to lower the cost burden.
Methods: 30 eyes of 30 patients diagnosed with proliferative diabetic retinopathy and have randomized for either pan retinal laser photocoagulation or intravitreal Bevacizumab every 4 weeks based on retreatment protocol both groups can receive intravitreal bevacizumab or focal/grid laser for diabetic macular edema.
Main outcome and measures: A complete exam including best corrected visual acuity changes within 52 weeks, improvement in diabetic retinopathy, central retinal thickness and cost analysis.
Results: Best corrected visual acuity changed from the baseline 0.60 LogMAR in the of Bevacizumab group and 0.50 LogMAR in the PRP group, to 0.40 LogMAR in the Bevacizumab group and 0.50 LogMAR in the PRP group at week 52 (P=0.14), where central retinal thickness changes at 52 weeks from baseline -48 (-62 to -32) in the Bevacizumab group and -16 (-21 to -8) in the PRP group (p<0.001) however proportion of eyes without active or regressed neovascularization at 52 weeks are statistically not significant between two groups (p=0.43).
Conclusion: Intravitreal Bevacizumab is non-inferior to pan retinal photocoagulation interim of visual acuity outcome within 52 weeks in case of proliferative diabetic retinopathy and may be more cost effective in selected cases of proliferative diabetic retinopathy with diabetic macular edema than both panretinal photocoagulation and Ranibizumab but a long term and larger studies are needed.
Laser Therapy for Diabetic Retinopathy and Diabetic Macular Edema
publication date Jun 1, 2017 publication descriptionRetina Today
Laser is still the treatment of choice in patients with PDR and non–center-involving CSME. In central DME, laser can be used as an adjuvant treatment to reduce the need for intravitreal injections and to delay the need for retreatment. Use of SDM laser may be safer and more effective than conventional CW laser, with better visual outcomes.
• In eyes with vitreous hemorrhage as a complication of PDR, laser can help to prevent further vitreous hemorrhage and encourage its clearance.
• It is important to be very familiar with the laser machine and lenses you plan to use before applying laser treatment in PDR and DME.
• Laser has a place as both first- and second-line therapy for DME, but it should always be combined with good glycemic control (HbA1C of 7% or less).
• When laser treatment for DME is planned, it is recommended to use OCT maps or fluorescein angiography as a guide to ensure accurate laser placement.
Effect of Intravitreal Aflibercept on Choroidal Neovascularization Membrane Secondary to Post Traumatic Choroidal Rupture
Apr 19, 2017
Purpose: To report the efficacy and safety of intravitreal ziv-aflibercept in a young female with choroidal neovascularization membrane secondary to post traumatic choroidal rupture.
Methods:T his was interventional case report, of a symptomatic 15 years’ old female with history of blunt trauma presented for reduced vision, underwent for clinical examination and fluorescein angiography at baseline and 12 weeks of treatment with three consecutive intravitreal injection of ziv-aflibercept1.25 mg every 4 weeks with evaluation of ocular and systemic complications.
Results: Improvement of best corrected visual acuity from baseline LogMAR 0.30 and 0.10 at 12 weeks with marked regression of choroidal neovascularization membrane on fluorescein angiogram a 12 weeks from baseline with no signs of ocular nor systemic complications.
Conclusions: Ziv-Aflibercept seems to be safe and effective in treatment of choroidal neovascularization membrane post traumatic choroidal rupture for 12 weeks follow up.
Free Medical Retina for the Poor
Mar 15, 2017
Treatment of retinal disease can be a huge burden for the patients causing
financial issues and thus can be added to war circumstances that made poverty
pandemic especially in elderly individuals, so the free medical retina service can
offer relief and improve quality of life for the poor by funding it from rich people
using the zakkah system.
Clinical Pathology of Diabetic Retinopathy and Macular Edema
Open Access Journal of Ophthalmology
Diabetic retinopathy and macular edema is multifactorial complex disease, VEGF can play central role in non- chronic diabetic macular edema pathogenesis and VEGF blockade agents may improve vision, where in chronic diabetic macular edema inflammatory cytokines are the main driver of edema and intravitreal steroids may result in edema resolution, however vascular element is not always the cause of macular thickening and visual loss from non- vascular elements such as vitreomacular abnormalities which needs to be managed surgically, while diabetic retinopathy can be non-proliferative or proliferative in the presence of neovascularization which they managed by pan retinal laser photocoagulation and proliferation can complicate in to tractoinal retinal detachment and vitreous hemorrhage, which may require surgical management in certain cases.
Using Steroids in Diabetic Macular Edema: A Guide for Steroid Application in Clinical Practice
Diabetic macular edema is a multi-pathogenic diseases which vascular endothelial growth factor (VEGF) may play the main role in most of the cases and treatment with Anti VEGF is warranted, where in long standing edema in ammation maybe the main pathogenic factor and treatment with Anti VEGF may not achieve optimum results and steroids can be used to address the in ammatory mechanism, there are three classes of intravitreal steroids which help us to individualize treatment for each patient never the less we have to take into account that all intravitreal steroids may cause cataract formation and glaucoma.
Using Anti-VEGF in Diabetic Retinopathy
Jun 27, 2016
Adv Ophthalmol Vis Syst
Vascular endothelium growth factor is the main pathological factor in diabetic retinopathy and diabetic macular edema (DME), Anti-VEGF agents are safe and effective in DME treatment, there are multiple Anti-VEGF agents, choosing between them is essential to individualize treatment for each patient to achieve the optimum results.
Management of Diabetic Macular Edema
Apr 1, 2016
An algorithm for treatment decision-making
Pearls for Treating Patients With Diabetic Retinopathy
Jan 1, 2016
An illustrated, step-by-step guide to management
Three-month outcome of ZIV-AFLIBERCEPT for diabetic macular edema
May 16, 2016
Purpose: Is to show the 3-month efficacy and safety of treatment diabetic macular edema treated with intravitreal ziv-aflibercept as studies have shown that Ziv-aflibercept does not cause retinal pigment epithelial toxicity and to study it cost effectiveness.
Methods: Ten eyes in eight patients diagnosed with central diabetic macular edema were enrolled for three consecutive intravitreal injection of ziv-aflibercept 1.25 mg every 4 weeks, a complete exam including BCVA and CRT at baseline and 12 weeks with evaluation of ocular and systemic complications.
Results: Improvement of best corrected visual acuity was clinically significant from baseline LogMAR 0.77 and 0.35 at 12 weeks and statistically significant (P<0.05) along with reduction of central retinal thickness from 562,4 µm and 317.7 µm at 12 weeks follow up (P<0.05) with no signs of ocular nor systemic complications.
Conclusion: Ziv aflibercept is a safe and effective in diabetic macular edema treatment for 12 weeks follow up with cost effectiveness especially in countries where aflibercept is not available.
Keywords: dme, anti vegf, vegf trap, diabetes, diabetic retinopathy, zaltrap, ziv aflibercept
Decisions for Imaging in DME
Jul 1, 2015
A brief guide to diagnosis and management with images